Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Would you like a patch test? *

Yes

No

Have you had Brazilian waxing before?
 *

Yes

No

Are you currently using, or have in the past, any of the following: Retin-A, Renova or Accutane (an oral form of Retin-A)? *

Yes

No

Skin thinning products and/or drugs, i.e.: anti-aging face cream? *

Yes

No

Sunbeds in the past 24 hours? *

Yes

No

Are you diabetic? *

Yes

No

Do you have any allergies? *

Yes

No

Have you had any recent surgery? *

Yes

No

Have you had tinting before with us? *

Yes

No

I agree that all of the information provided is accurate

Option One

Option Two